Healthcare Provider Details

I. General information

NPI: 1104252154
Provider Name (Legal Business Name): PHILIP M WORTHINGTON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2013
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 PORTSMOUTH AVE
DAVIS CA
95616-2737
US

IV. Provider business mailing address

631 PORTSMOUTH AVE
DAVIS CA
95616-2737
US

V. Phone/Fax

Practice location:
  • Phone: 804-248-1036
  • Fax:
Mailing address:
  • Phone: 804-248-1036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDDS112333
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number10809
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10809
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: